World Health Organization infant and young child feeding indicators and their associations with child anthropometry: a synthesis of recent findings

As the World Health Organization (WHO) infant and young child feeding (IYCF) indicators are increasingly adopted, a comparison of country-specific analyses of the indicators\u27 associations with child growth is needed to examine the consistency of these relationships across contexts and to assess the strengths and potential limitations of the indicators. This study aims to determine cross-country patterns of associations of each of these indicators with child stunting, wasting, height-for-age z-score (HAZ) and weight-for-height z-score (WHZ). Eight studies using recent Demographic and Health Surveys data from a total of nine countries in sub-Saharan Africa (nine), Asia (three) and the Caribbean (one) were identified. The WHO indicators showed mixed associations with child anthropometric indicators across countries. Breastfeeding indicators demonstrated negative associations with HAZ, while indicators of diet diversity and overall diet quality were positively associated with HAZ in Bangladesh, Ethiopia, India and Zambia (P \u3c 0.05). These same complementary feeding indicators did not show consistent relationships with child stunting. Exclusive breastfeeding under 6 months of age was associated with greater WHZ in Bangladesh and Zambia (P \u3c 0.05), although CF indicators did not show strong associations with WHZ or wasting. The lack of sensitivity and specificity of many of the IYCF indicators may contribute to the inconsistent associations observed. The WHO indicators are clearly valuable tools for broadly assessing the quality of child diets and for monitoring population trends in IYCF practices over time. However, additional measures of dietary quality and quantity may be necessary to understand how specific IYCF behaviours relate to child growth faltering

The impact of integrated prevention and treatment on child malnutrition and health: the PROMIS project, a randomized control trial in Burkina Faso and Mali

Abstract Background Evidence suggests that both preventive and curative nutrition interventions are needed to tackle child acute malnutrition (AM) in developing countries. In addition to reducing the incidence of AM, providing preventive interventions may also help increase attendance (and coverage) of AM screening, a major constraint in the community-based management of child acute malnutrition (CMAM) model. There is a paucity of evidence-based strategies to deliver integrated preventive and curative interventions effectively and affordably at scale. The aim of the Innovative Approaches for the Prevention of Childhood Malnutrition (PROMIS) study is to assess the feasibility, quality of implementation, effectiveness and cost-effectiveness of an integrated child malnutrition prevention and treatment intervention package implemented through a community-based platform in Mali and a facility-based platform in Burkina Faso. Methods/Design The PROMIS intervention entails a comprehensive preventive package offered on a monthly basis to caregivers of children, while children are screened for acute malnutrition (AM). The package consists of behavior change communication on essential nutrition and hygiene actions, and monthly preventive doses of small quantity lipid-based nutrient supplements (SQ-LNS) for children aged 6 to 23.9 months. Positive AM cases are referred to treatment services offered by first-line health services according to the CMAM model. The PROMIS intervention will be evaluated using a mixed methods approach. The impact study encompasses two types of study design: i) repeated cross-sectional surveys conducted at baseline and at endline after 24 months of program implementation and ii) a longitudinal study with a monthly follow-up for 18 months. Primary study impact measures include the incidence and endpoint prevalence of AM, AM screening coverage and treatment compliance. A process evaluation will assess the feasibility and quality of implementation of the intervention guided by country specific program impact pathways (PIPs). Cost-effectiveness analysis will assess the economic feasibility of the intervention. Discussion The PROMIS study assesses the effectiveness of an innovative model to integrate prevention and treatment interventions for greater and more sustainable impacts on the incidence and prevalence of AM using a rigorous, theory-based randomized control trial approach. This type of programmatic research is urgently needed to help program implementers, policy makers, and investors prioritize, select and scale-up the best program models to prevent and treat AM and achieve the World Health Assembly goal of reducing childhood wasting to less than 5% globally by the year 2025. Trial registration Clinicaltrials.gov NCT02323815 (registered on December 18, 2014) and NCT02245152 (registered on September 16, 2014

Reply to Correspondence: is the strength of association between indicators of dietary quality and the nutritional status of children being underestimated?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102165/1/mcn12107.pd

Information Diffusion and Social Norms Are Associated With Infant and Young Child Feeding Practices in Bangladesh

Background Interaction within mothers’ social networks can theoretically diffuse messages from interventions and campaigns into norms and practices for infant and young child feeding (IYCF). Objectives We hypothesized that mothers’ social networks, diffusion of information, and social norms differed in intensive [intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM)] compared with nonintensive (standard IPC and less-intensive CM and MM) intervention areas, were associated with IYCF practices, and partly explained practice improvement. Methods We conducted household surveys at endline in 2014 and follow-up in 2016 (n = ∼2000 each round). We used multiple regression to test differences and changes in networks, diffusion, and norms within intervention areas. We analyzed paths from intervention exposure to IYCF practices through networks, diffusion, and norms. Results Mothers’ networks were larger in intensive than in nonintensive areas in 2014 and increased in both areas over time [25–38 percentage points (pp)]. The prevalence of receipt of IYCF information was high, with no changes over time in intensive areas but an increase in nonintensive areas (8–16 pp). In both areas, more family members and health workers provided IYCF information over time. Sharing of information increased 17–23 pp in intensive and 11–41 pp in nonintensive areas over time. Perceived descriptive norms improved 8–16 pp in intensive and 17–28 pp in nonintensive areas. Perceived injunctive norms were high in both areas. Breastfeeding practices were associated with networks, diffusion, and norms (OR: 1.6–4.4 times larger comparing highest with lowest quartile). Minimum dietary diversity was associated with larger networks and diffusion (OR: 1.5–2.2) but not with social norms. Indirect paths from intervention exposure to practices explained 34–78% of total effects. Conclusions Diffusion of IYCF information through social networks, reinforced by positive social norms for messages promoted over time, will contribute to positive changes in IYCF practices that may be achieved and sustained through large-scale social and behavior change interventions. This trial was registered at clinicaltrials.gov as NCT0274084

Behavior Change Intervention Research In Infant And Young Child Feeding: Understanding Caregiver Capabilities, Self-Efficacy, And The Critical Decisions That Define Infant Feeding Trajectories In Bangladesh

Behavior change interventions (BCIs) have been used to improve infant and young child feeding (IYCF) practices with varying success. This may result from inadequate consideration of determinants of behavior, including "caregiver capabilities." We aimed to: 1) examine the extent to which caregiver capabilities are considered in research on complementary feeding BCIs in low- and middle-income countries, 2) describe IYCF trajectories from 0 to 11 months of age and explore caregiver decisions at critical IYCF junctures, and 3) examine the role of caregiver self-efficacy for complementary feeding as part of a program impact pathway to improved behaviors. We conducted a scoping study of the peer-reviewed complementary feeding BCI literature (objective 1); used ethnographic methods to collect and analyze in-depth qualitative longitudinal interviews from the process evaluation the Alive & Thrive BCI in Bangladesh (objective 2); and conducted structural equation modeling to test the direct and indirect effects of self-efficacy for two complementary feeding behaviors (objective 3) using survey data from a process evaluation of the Alive & iii Thrive BCI in Bangladesh. In the scoping study (objective 1), we found that caregiver capabilities are rarely mentioned, intervened on, or measured in BCI research on complementary feeding, revealing considerable gaps in this literature. In the study of IYCF trajectories (objective 2), we observed substantial intra-cultural diversity, resulting from a combination of child, caregiver, and household factors, suggesting no normative longitudinal patterns for IYCF in this study population. We identified consequential junctures in IYCF, "decision moments," that determined each child's IYCF trajectory. These findings indicate the value of individually tailored interventions to effectively target decision moments. The Alive & Thrive BCI improved two complementary feeding behaviors that we analyzed (objective 3). For one behavior, feeding green leafy vegetables, the BCI operated though self-efficacy and mothers with greater selfefficacy were more likely to practice this behavior. For the second behavior, on-time introduction of egg, the BCI did not work through self-efficacy, likely due to women's lack of resources, autonomy, and access to markets. The use of multiple methods advanced our understanding of intervention pathways and highlighted the important roles of caregiver capabilities in this context. i

The pathways from a behavior change communication intervention to infant and young child feeding in Bangladesh are mediated and potentiated by maternal self-efficacy

In the context of a behaviour change intervention (BCI) in Bangladesh, we studied the role of maternal self-efficacy for complementary feeding (MSE-CF) for 2 complementary feeding (CF) behaviors with the use of a theoretically grounded empirical model of determinants to illustrate the potential roles of MSE-CF. MSE-CF was a significant mediator and potentiator for GLV but not for EGG. The divergent findings highlight the complex determinants of individual specific infant and young child feeding behaviors. The study shows the value of measuring behavioral determinants, such as MSE-CF, that affect a caregiver's capability to adopt intervention-targeted behaviors.PRIFPRI3; ISI; CRP4; Alive and Thrive; 2 Promoting Healthy Diets and Nutrition for all; 4 Transforming Agricultural and Rural Economies; G Cross-cutting gender theme; Capacity StrengtheningPHND; A4NHCGIAR Research Program on Agriculture for Nutrition and Health (A4NH

Behavior Change Intervention Research In Infant And Young Child Feeding: Understanding Caregiver Capabilities, Self-Efficacy, And The Critical Decisions That Define Infant Feeding Trajectories In Bangladesh

Behavior change interventions (BCIs) have been used to improve infant and young child feeding (IYCF) practices with varying success. This may result from inadequate consideration of determinants of behavior, including "caregiver capabilities." We aimed to: 1) examine the extent to which caregiver capabilities are considered in research on complementary feeding BCIs in low- and middle-income countries, 2) describe IYCF trajectories from 0 to 11 months of age and explore caregiver decisions at critical IYCF junctures, and 3) examine the role of caregiver self-efficacy for complementary feeding as part of a program impact pathway to improved behaviors. We conducted a scoping study of the peer-reviewed complementary feeding BCI literature (objective 1); used ethnographic methods to collect and analyze in-depth qualitative longitudinal interviews from the process evaluation the Alive & Thrive BCI in Bangladesh (objective 2); and conducted structural equation modeling to test the direct and indirect effects of self-efficacy for two complementary feeding behaviors (objective 3) using survey data from a process evaluation of the Alive & iii Thrive BCI in Bangladesh. In the scoping study (objective 1), we found that caregiver capabilities are rarely mentioned, intervened on, or measured in BCI research on complementary feeding, revealing considerable gaps in this literature. In the study of IYCF trajectories (objective 2), we observed substantial intra-cultural diversity, resulting from a combination of child, caregiver, and household factors, suggesting no normative longitudinal patterns for IYCF in this study population. We identified consequential junctures in IYCF, "decision moments," that determined each child's IYCF trajectory. These findings indicate the value of individually tailored interventions to effectively target decision moments. The Alive & Thrive BCI improved two complementary feeding behaviors that we analyzed (objective 3). For one behavior, feeding green leafy vegetables, the BCI operated though self-efficacy and mothers with greater selfefficacy were more likely to practice this behavior. For the second behavior, on-time introduction of egg, the BCI did not work through self-efficacy, likely due to women's lack of resources, autonomy, and access to markets. The use of multiple methods advanced our understanding of intervention pathways and highlighted the important roles of caregiver capabilities in this context. i

Insights from nationally representative data

PRIFPRI3; ISI; CRP4PHND; A4NHCGIAR Research Program on Agriculture for Nutrition and Health (A4NH

Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali.

BackgroundCommunity-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence.Methods and findingsA two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6-23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers' participation and supplement children's diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p ConclusionsIncorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated.Trial registrationClinicalTrials.gov NCT02323815

Impact on child acute malnutrition of integrating a preventive nutrition package into facility-based screening for acute malnutrition during well-baby consultation: A cluster-randomized controlled trial in Burkina Faso.

BackgroundCommunity management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM's effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children Methods and findingsWe used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0-17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was α = 0.016 after adjustment for multiple testing. Children's average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10-26, P ConclusionsAdding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery.Trial registrationClinicalTrials.gov NCT02245152